Please Read Three Days Before
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Patient Instruction Packet Please read the information in this packet at least 5 DAYS prior to the time of your scheduled appointment. Please complete pages 4 thru 7 and page 18 Bring this entire patient packet with you on the day of your appointment. Please complete Page 8 ONLY if your procedure is related to an Injury / Accident. Brooklyn Surgery Center 6010 Bay Parkway, 4th Floor Brooklyn, NY 11204-2569 Tel: 718 259-4272 Fax: 718 259-1582 www.brooklynsurgerycenter.com Please complete the forms on Pages 4 thru 7 and page 17, Bring the entire packet with you on the day of your appointment. Please complete Page 8 ONLY if your procedure is related to an Injury / Accident. PAGE Welcome Notice 3 *Patient Registration Sheet 4 * Pre Procedure Questionnaire and Medication List 5 *Uniform Assignment and Release of Information Statement 6 *Notice of Participation in Health Insurance Plans 7 *ASC Accident/Injury Questionnaire 8 Financial Policy 9 Patient Self-Determination Act/Advance Directives 10 Patient’s Rights 11 Patient Has a Responsibility to 12 Ownership Disclosure 13 Notice of Privacy Practices 14-16 Escort & Personal Possessions Policy 17 *Patient Acknowledgment of Advance Notices 18 FAQs (Frequently Asked Questions) 19-20 Directions to Brooklyn Surgery Center 21 Procedure Information Sheets Gastroenterology 22 Procedure Information Sheets Orthopedics 23 Procedure Information Sheets Reproductive Endocrinology and Infertility and GYN 24 Procedure Information Sheets Pain Management 25 CLINICAL: Patient Packet: 2015 updated 2019 PAGE 2 OF 25 Welcome Notice Welcome to Brooklyn Surgery Center (BSC). Our mission is to provide high-quality ambulatory medical/surgical/ care and related services to our community, considerate of the specific needs of individual patients. The Center’s mission is to serve all persons in need of medical/surgical care and related services, regardless of age, color, race, creed, national origin, religion, gender, marital status, disability, payer source, or any other personal characteristic or qualification, including the ability to pay. BSC serves as a valuable health care resource, offering high-quality clinical care across several medical disciplines, including Gastroenterology, Female and Male Reproductive Endocrinology, and Fertility, Gyn, Orthopedics, Pain Management, Podiatry, General Surgery, Urology, and Colorectal Surgery. The Center is licensed by New York State as an Article 28 free standing Ambulatory Surgery Center, is accredited by the Center for Medicare and Medicaid Services (CMS) and the Accreditation Association for Ambulatory Health Care (AAAHC). Our community-based physicians, surgeons and staff endeavor to achieve excellence inpatient . Brooklyn Surgery Centers physicians and staff take pride in serving the healthcare needs of our diverse and widespread community. Our patients and their families have embraced the Center as an integral part of their community. BSC is committed to maintaining and exceeding national quality standards and is recognized as an innovative leader in the future of ambulatory surgery services for our community. Further information on BSC can be found on our website: www.brooklynsurgerycenter.com PAGE 3 OF 25 Patient Registration Today’s Date _ Date of Birth Age Gender M F Marital Status S M W D Patient Name (First Name) (MI) (Last Name) Address (Street) (Apt#) (City) (State) (Zip Code) (County) Home Phone Cell Phone _ Alternate Phone E-mail Address Name of Spouse/ Partner Cell Phone Alternate Phone Ethnicity – Do you consider yourself Hispanic/Latino? Y N Declined Unavailable/Unknown Primary Language Race: Which category best describes your race? American Indian/Alaskan Native Asian Indian Asian Native Hawaiian/Pacific Islander Guamanian/Chamorro Samoan Mexican American/Chicano Puerto Rican Cuban Black or African American White Multiracial_ Declined Unavailable/Unknown Other Employer Occupation W ork Phone Address Name and Phone number of the person that will escort you upon discharge from the Center ( ) Emergency Contact _ Telephone Relationship ************************************************************************************************************************************************************************************ Primary Doctor Address Telephone Fax Referring Doctor Address Telephone _ Fax ************************************************************************************************************************************************************************************* Do you have any allergies? Yes No Allergies to Latex? Yes No Allergies to food? [Please list] Allergies to medications? Yes No [Please list drug names] ************************************************************************************************************************************************************************************* Primary Insurance Company Name Hosp Medical Ins Phone # Address Group # ID # Name of Insured Date of Birth SS # Relationship Secondary Ins. Company Name _ Hosp Medical Ins Phone # Address Group # ID # Name of Insured Date of Birth SS # Relationship _ I certify the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare), for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER’S CURRENT RATE, MAY BE CHARGED on all balances owing to the provider that are past due. I permit a copy of this release to be used in place of the original. Signature: (Signature of an insured or authorized person, legal guardian if minor) Date Do You Have A Health Care Proxy No Yes If Yes, Type: Copy Provided? No Yes Do You Have A Living Will? No Yes If yes, type: Copy Provided? No Yes ******************************************************************************************************************************************************* If an interpreter is necessary, please sign below indicating the patient understands and agrees to the terms herein. Interpreter’ s Signature: Date_ PAGE 4 OF 25 PRE PROCEDURE QUESTIONAIRE/MEDICATION LIST NAME: HT: WT:_ CURRENT MEDICATIONS- Please list all current prescriptions, over-the-counter medications, including MAO’s, vitamins, and supplements. Prescription Medications Dosage/ Date of Prescription Medications Dosage/ Date of Frequency Last Dose Frequency Last Dose Over-the-Counter Vitamins or Dosage/ Date of Herbal Supplement Frequency Last Dose ALLERGIES No Allergies Penicillin Sulfa Aspirin Iodine Latex Soy Eggs Other If you have allergies, describe reaction(s): MEDICAL HISTORY- Please all that apply: Acid Reflux Chronic lung disease Gout Kidney Infection Sleep Apnea Anemia Chronic sinusitis Heart attack Kidney Stones Stroke/paralysis Arthritis Cirrhosis of liver Heart failure Liver Disease (Tuberculosis) Asthma Thyroid disease Heart Murmur Lupus Ulcerative Colitis Bleeding disorder Colon cancer Hepatitis Multiple sclerosis Other:_ Blood clots Colon polyps Hiatal/Groin hernia Pancreatitis Blood Transfusion Crohn’ s Disease High blood pressure Parkinson’ s disease Cancer Diabetes HIV or AIDS Phlebitis Chest pain/angina Diverticulitis Irregular heartbeat Polio Chronic anxiety Emphysema Irritable bowel syndrome Radiation therapy Chronic cough Glaucoma Kidney disease/failure Seizures SURGICAL HISTORY- Include all surgeries/procedures and dates. Please be specific._ Female Patients: When was your last menstrual cycle? /_ /_ Could you be pregnant? No Yes CURRENT MEDICAL CONDITIONS ANESTHESIA HISTORY Do you use oxygen? No Yes Have you ever had anesthesia? No Yes Are you taking any MAOIs? No Yes Have you ever had a problem with anesthesia? No Yes Have you taken any prednisone or other steroids Has any member of your family had a problem with anesthesia? No Yes for your breathing in the last 3 months? No Yes No Pre-procedure testing required. Have you had pneumonia or bronchitis Pre-procedure testing required. in the past 6 months? No Yes Smoking history No Yes; packs/day for years Currently smoking? No Yes Alcohol No Yes; amount per day: Do you have: loose/chipped/capped teeth? No Yes Bridges/dentures? No Yes Trouble opening mouth or jaw clicking? No Yes Reviewing Nurse Print Name Signature Time Date PAGE 5 OF 25 UNIFORM ASSIGNMENT AND RELEASE OF INFORMATION STATEMENT Name: Med. Rec. #: AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize and direct the above named medical facility, having treated me, to release governmental agencies, insurance carriers, or others who are financially liable for my medical care, all information needed to substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. I also authorize Brooklyn Surgery Center, to release medical information in the event of any emergency transfer to an Acute Care Facility. If I am transferred to or admitted to other institutions in relation to my procedure, I authorize the release of all my medical records pertaining to that transfer or admission to Brooklyn Surgery Center. Signature of Patient or Authorized Representative Date ASSIGNMENT OF BENEFITS I hereby assign, transfer and set over to the above named medical facility sufficient monies and/or benefits to which I may be entitled to government agencies, insurance carriers, or others who are financially